Superior sagittal sinus thrombosis after spinal anesthesia.

Superior sagittal sinus thrombosis is an uncommon phenomenon that could occur in patients with a risk for thrombosis. It has been reported after spinal anesthesia with persistent cerebrospinal fluid leak. The current case is a young 29-year-old man who was complaining of persistent headache after spinal anesthesia for varicocelectomy and a new onset of blurred vision with a sign of papilledema. The diagnosis was confirmed with magnetic resonance imaging and proved to be superior sagittal sinus thrombosis. He was started on anticoagulant therapy and showed gradual improvement. No previous case has been reported in the literature in a patient without prothrombotic status risk.

Does surgical delay for radical prostatectomy affect biochemical recurrence? A retrospective analysis from a Canadian cohort.

AIM: We sought to explore the impact of surgical wait time (SWT) to robot-assisted radical prostatectomy (RARP) on biochemical recurrence (BCR). METHOD: Retrospective review of a prospectively collected database between 2006 and 2015 was conducted on all RARP cases. SWT was defined as period from prostate biopsy to surgery. Primary outcome was the impact on BCR, which was defined as two consecutive PSA ≥ 0.2 ng/dl, or salvage external beam radiation therapy and/or salvage androgen deprivation therapy. Patients were stratified according to D'Amico risk categories. Univariable analysis (UVA) and multivariable analyses (MVA) with a Cox proportional hazards regression model were used to evaluate the effect of SWT and other predictive factors on BCR, in each D'Amico risk group and on the overall collective sample. RESULTS: Patients eligible for analysis were 619. Mean SWT was 153, 169, 150, and 125 days, for overall, low-, intermediate-, and high-risk patients, respectively. Multivariate analysis on the overall cohort did not show a significant relation between SWT and BCR. On subgroup analysis of D'Amico risk group, SWT was positively correlated to BCR for high-risk group (p = 0.001). On threshold analysis, cut-off was found to be 90 days. SWT did not significantly affect BCR on UVA and MVA in the low- and intermediate-risk groups. CONCLUSION: Increased delay to surgery could affect the BCR, as there was a positive association in high-risk group. Further studies with longer follow-up are necessary to assess the impact of wait time on BCR, cancer specific survival and overall survival.

Erectile function recovery after robotic-assisted radical prostatectomy (RARP): long term exhaustive analysis across all preoperative potency categories.

INTRODUCTION: To evaluate erectile function recovery following robotic-assisted radical prostatectomy (RARP) according to preoperative sexual health inventory for men (SHIM) score stratification. MATERIALS AND METHODS: We prospectively collected data on 250 consecutive patients who underwent RARP by a single surgeon between October 2006 and October 2012. Thirty-six patients were excluded because of lack of preoperative SHIM score. All patients had a minimum follow up of 2 years. Patients were divided into four groups according to their preoperative SHIM score: group 1 with normal potency (SHIM 22-25), group 2 with mild ED (SHIM 17-21), group 3 with mild-moderate ED (SHIM 12-16) and group 4 with moderate-severe ED (SHIM 1-11). Patients were followed at 3, 6, 9, 12, 18, 24 months intervals and twice yearly thereafter. SHIM questionnaire and erection hardness scale (EHS) score were collected at each visit. Potency was defined as successful penetration during intercourse (EHS score 3-4) with or without phosphodiesterase type 5-inhibitor (PDE5-I). RESULTS: After exclusion, 214 patients were evaluated. The number of patients in group 1, 2, 3 and 4 were 95, 59, 26 and 34, respectively. At 3, 6, 9, 12, 18, 24 months, SHIM scores and potency rates were statistically different between groups 1 versus 2 versus 3 versus 4 (p < 0.01, at each time point). Patients in each group 1, 2 and 3 showed a statistically significant improvement in potency rates and SHIM scores at consecutive follow up visits up to 24 months (p < 0.01, for each potency group). Potency rates at 24 months for groups 1 to 4 were 83.3%, 54.5%, 50.0%, and 20.7%, respectively (p < 0.001). CONCLUSION: For proper patient counseling and better prediction of erectile function recovery after RARP, it is important to stratify patients according to preoperative SHIM scores. Setting realistic expectations may increase patient satisfaction.

Robotic transmesocolonic Pyelolithotomy of horseshoe kidney.

INTRODUCTION: The purpose of this video is to demonstrate the use of the robot to perform a transmesocolonic pyelolithotomy of a horseshoe kidney. MATERIALS AND METHODS: A 35-year old female presented with vague abdominal pain. CT scan imaging revealed the presence of a left horseshoe kidney with multiple pelvicalyceal stones. The patient was positioned in the supine position. A total of 4 ports were introduced. A 3-arm da Vinci robotic surgical system was docked, and the arms were connected. First, the dilated renal pelvis was identified behind the thin mesocolon. The mesocolon was entered and renal pelvis was dissected completely from the surrounding fat. Then, the renal pelvis was opened after adequate dissection and stones were visualized inside the calyces. By Prograsp forceps, stones were removed from all the calyces under vision and were extracted from the assistant trocar. Finally, the pylotomy incision was closed using 4 0 Maxon in a continuous fashion and the mesocolon was closed using 3 0 PDS interrupted sutures. A JP drain was placed. RESULT: Operative time was forty-five minutes, blood loss was 100 ml. The patient was discharged after 48 hours with no immediate complications. CONCLUSION: The utilization of minimal invasive surgery using the robot to extract multiple pelvicalyceal stones from a horseshoe kidney without reflecting the mesocolon proved to be a feasible and novel way in the management of complex stone disease improving the outcome with minimal morbidity.

Robotic extramucosal excision of bladder wall leiomyoma.

INTRODUCTION: Multiple case reports and reviews have been described in the literature for bladder wall leiomyoma resection via different approaches. The minimally invasive partial cystectomy remains the most widely accepted technique; however, case reports for enucleation of bladder wall leiomyoma have also been described. The purpose of this video is to demonstrate the robotic extramucosal excision of a bladder wall leiomyoma, without cystotomy, but with complete removal of the muscular layer. MATERIALS AND METHODS: A 35-year old male present with lower urinary tract symptoms and imaging showed bladder wall mass with histopathology showed leiomyoma. The patient consented for mass excision with the possibility of a partial cystectomy. The patient was placed in the supine, 30-degree Trendelenburg position during the procedure. A total of 4 ports were inserted. A 3-arm da Vinci robotic surgical system was docked, and the arms were connected. Extramucosal excision was accomplished without cystotomy and muscle approximation was achieved by 2 0 Vicryle. RESULT: The operative time was 90 minutes, blood loss of approximately 50mL and the patient was discharged after 72 hours with no immediate complications and a 6 months follow-up showed no recurrence. CONCLUSION: Such a technique results in complete excision of the tumor, without cystotomy, and also maintains an intact mucosa. These steps, in addition to decreasing the risk of local recurrence, also shorten the period of postoperative catheterization and hospitalization.

Hematuria: Is it useful in predicting renal or ureteral stones in patient presenting to emergency department with flank pain?

Objectives: The objective of the study was to evaluate hematuria as a diagnostic test for renal and ureteral stones compared with a noncontrast-enhanced computed tomography (CT) scan (gold standard test) in emergency room patients with acute flank pain. Patients and Methods: In total, 604 patients treated in our emergency department from 2006 to 2011, with a history of flank pain and suspected urolithiasis were included in a retrospective review. All patients were evaluated with a noncontrast-enhanced CT scan and urine analysis. Using the noncontrast CT scan as the gold standard for the evaluation of the presence, number, size, and site (renal or ureteral [upper, middle, and lower]) of the stones, we calculated the sensitivity, specificity, and positive and negative predictive values of hematuria for diagnosing both renal and ureteral stones. Results: Urolithiasis was diagnosed in 388 patients (64%) and 216 patients (36%) had no stones on a noncontrast-enhanced CT scan. The sensitivity, specificity, positive predictive value, and negative predictive value for microhematuria were 77%, 33%, 67%, and 45%, respectively. Microhematuria was more common in patients with ureteral stones only (139 patients) and had a sensitivity of 85% compared to patients with renal stones only (32 patients), with a sensitivity of 55% (P < 0.001). There were no significant differences in the specificity or positive or negative predictive values. Conclusion: Although microhematuria is more sensitive to ureteral stones, the absence of microhematuria does not exclude the possibility of urolithiasis and a noncontrast-enhanced CT scan should be the gold standard diagnostic tool.

Emphysematous sloughed floating ball after prostate water vaporization Rezum: A case report.

BACKGROUND: Rezum™ water vapor therapy is a new minimally invasive endoscopic technology for the management and treatment of benign prostatic hyperplasia. CASE SUMMARY: A 63-year-old male presented to our department with severe dysuria, frequency, urgency, and interrupted stream 2 mo after receiving Rezum™ therapy. The symptoms were caused by a retained floating emphysematous necrotic sloughed tissue. We also discovered a persistent bacterial infection that was resistant to parenteral antimicrobial therapy. The treatment of the patient included surgical removal of the necrotic tissue. CONCLUSION: Despite the good safety profile and minimal adverse events related to Rezum™ therapy, major complications can still occur.

Declined Humoral Immunity of Kidney Transplant Recipients to SARS-CoV-2 Vaccines.

Background: Kidney transplant recipients (KTRs) commonly suffer from impaired immunity. KTRs' compromised immune response to COVID-19 vaccines indicates urgent revision of immunisation policies. Methods: A cross-sectional study was conducted in Madinah, Saudi Arabia of 84 KTRs who had received at least one dose of a COVID-19 vaccine. ELISA was used to evaluate anti-spike SARS-CoV-2 IgG and IgM antibody levels in blood samples obtained one month and seven months after vaccination. Univariate and multivariate analyses were performed to identify associations between seropositive status and factors such as the number of vaccine doses, transplant age, and immunosuppressive therapies. Results: The mean age of KTRs was 44.3 ± 14.7 years. The IgG antibody seropositivity rate (n=66, 78.5%) was significantly higher than the seronegativity rate (n=18, 21.4%) in the whole cohort (p<0.001). In KTRs seroconverting after one month (n=66), anti-SARS-CoV-2 IgG levels declined significantly between one month (median [IQR]:3 [3-3]) and seven months (2.4 [1.7-2.6]) after vaccination (p<0.01). In KTRs with hypertension, IgG levels significantly decreased between one and seven months after vaccination (p<0.01). IgG levels also decreased significantly in KTRs with a transplant of >10 years (p=0.02). Maintenance immunosuppressive regimens (triple immunosuppressive therapy and steroid-based and antimetabolite-based regimens) led to a significant decrease in IgG levels between the first and second sample (p<0.01). KTRs receiving three vaccine doses showed higher antibody levels than those receiving a single dose or two doses, but the levels decreased significantly between one (median [IQR]: 3 [3-3]) and seven months (2.4 [1.9-2.6]) after vaccination (p<0.01). Conclusion: KTRs' humoral response after SARS-CoV-2 vaccination is dramatically inhibited and wanes. Antibody levels show a significant decline over time in KTRs with hypertension; receiving triple immunosuppressive therapy or steroid-based or antimetabolite-based regimens; receiving mixed mRNA and viral vector vaccines; and with a transplant of >10 years.

Robotic-assisted excision of a juxta renal retroperitoneal schwannoma.

Retroperitoneal schwannoma is a rare benign tumor of the peripheral nerve Schwann sheath. We, herein, report the case of a 74-year-old woman who presented with vague abdominal pain. Computed tomography imaging revealed a retroperitoneal mass that is medial to the right kidney. The patient underwent robotic excision of the tumor with the pathology revealing schwannoma. We report this case due to the scarcity of this disease entity, especially at this location and to emphasize the indication and value of robotic technology in different pathological processes retroperitoneally.

Proximal corporal reconstruction: adjunct of penile prosthesis revision surgery.

Proximal corporal deformities may account for failed inflatable penile prosthesis (IPP) surgery. No contemporary series has focused solely on describing the natural history and management of isolated proximal corporal deformities in patients after IPP surgery. The aim of the current report is to present the clinical courses and surgical management with outcomes of proximal corporal deformities in the context of prior IPP implantation surgery. We conducted a retrospective analysis of the Johns Hopkins Hospital institutional database of IPP surgeries from May 2006 to March 2017 consisted of 198 patients who had undergone IPP revisions. All cases involving surgical revisions associated with isolated proximal corporal deformities (proximally from the penoscrotal junction) were identified. Data retrieved included clinical characteristics, operative findings, and surgical outcomes. Main outcome measures are the ability to achieve successful sexual intercourse after IPP revision. The findings of proximal corporal deformities were manifest in fifteen patients who had undergone previous IPP surgery. Deformities consisted of corporal dilatation (15 patients) and corporal rupture (8 patients). Associated prosthesis defects were mechanical failure (2 patients), aneurysmal dilatation (5 patients), and device breakage (4 patients). Median IPP treatment duration was 14 years. Mean number of prior IPP surgeries were 4.2 times. All patients underwent reduction corporoplasty with IPP device replacements consisting of controlled expansion devices. Mean age at revision was 59.7 years. All patients reported successful sexual intercourse and satisfaction within 6 months' follow-up after surgical revision. Proximal corporal deformities arising after IPP surgery are associated with dysfunctional device operation and as well as device defects. Proper recognition of this problem allows the opportunity for surgical correction with a definitive reduction corporoplasty. Failure to recognize these abnormalities timely may predispose to unsuccessful revisions and complicate future definitive surgical repair.

Primary infertility secondary to a hidden posterior urethral valve representing a diagnostic challenge in the fifth decade.

Posterior urethral valves (PUVs) are frequently recognized during the perinatal period. Delayed diagnosis is reported usually within the first decade of life with diverse clinical presentations. In the current case report, we describe a 45 years old man patient who presented with aspermia and primary infertility for 8 years in whom his diagnostic workup revealed radiological imaging suggestive of PUVs. This phenomenon was confirmed by cystourethroscopy that showed obstructive valve. Endoscopic ablation resulted in significant improvement of his seminal parameter with successful conception.

The Role of Phosphodiesterase Inhibitors in the Management of Cavernositis With Multifocal Abscesses: A Report of Case Series.

INTRODUCTION: Cavernositis is a rare acute infection of the corporal bodies of the penis. It might result in corporal cavernosal abscesses, fibrosis, and subsequently erectile dysfunction if the treatment is inadequate. Previous reports advocate penile aspiration when cavernosal abscesses were significantly present. AIM: We report 2 cases of cavernositis treated by the standard antimicrobial therapy in addition to the daily use of phosphodiesterase type 5 inhibitors (iPDE-5). METHODS: We include 2 patients who fulfill the criteria for the diagnosis of cavernositis. They were diagnosed clinically based on history and physical examination. Patient 1 had multifocal abscesses on initial penile contrast-enhanced magnetic resonance imaging (MRI). This patient showed rapid clinical improvement with the addition of phosphodiesterase inhibitor (PDEi) to the antimicrobial therapy without the need for surgical drainage of the abscesses. Patient 2 had persistent infection despite 3 weeks of oral second-generation cephalosporin (Cefuroxime). But he showed significant clinical improvement after being started on PDEi in conjunction with the current antimicrobial therapy. Follow-up after 3 months by clinical examination and penile magnetic resonance imaging in both patients showed normal erectile function with no scarring. CONCLUSION: PDEi have promising results on disease progression and outcomes. It synergizes the effect of antimicrobial therapy and can potentially reduce the residual corporal fibrosis and erectile dysfunction. However, large studies are required to validate and generalize this treatment approach. Bakhsh A, Daqqaq T, Alhasan A, et al. The Role of Phosphodiesterase Inhibitors in the Management of Cavernositis With Multifocal Abscesses: A Report of Case Series. Sex Med 2020;8:318-322.

Incidental discovery of an interstitial emphysematous cystitis with liver abscess: A report of hematogenous spread of infection.

Emphysematous cystitis is an unusual urological emergency in clinical practice. The disease characteristics are still underreported. It is characterized by the presence of gas in the urinary bladder wall secondary to gas forming organism. We report an incidental finding of emphysematous cystitis in a 35-year-old secondary to a huge liver abscess in a poorly controlled blood sugar. The infection spread hematogenously to the urinary bladder wall that was managed conservatively by urethral catheter drainage and hepatic abscess drainage in adjunct with antimicrobial therapy. The patient had no urinary symptoms. The bladder wall gas disappeared during follow-up in 2 weeks.

Long-term urinary functional outcome of vesicourethral anastomosis with bidirectional poliglecaprone (Monocryl®) vs. barbed polyglyconate suture (V-LocTM 180) in robot-assisted radical prostatectomy.

INTRODUCTION: We aimed to evaluate urinary continence recovery following robot-assisted radical prostatectomy (RARP) using monofilament poliglecaprone (Monocryl®) suture vs. barbed suture (V-LocTM 180) during vesicourethral anastomosis (VUA). METHODS: In this prospective, observational cohort, data were collected on 322 consecutive patients. All patients underwent continuous, bidirectional, single-layer running anastomosis with either 3.0 monofilament suture (n=141) or 3.0 barbed suture (n=181). The primary outcome was continence recovery defined as time to 0 pad at one, three, six, 12, and 24 months following surgery. RESULTS: Continence rates were significantly better with monofilament VUA at all followup time points up to one year. Median time to continence was one month vs. five months in the monofilament group vs. barbed group, respectively (p<0.001). Continence rates in monofilament suture vs. barbed group at one, three, six, 12, and 24 months were 56% vs. 26% (p<0.001), 73% vs. 36.4% (p<0.001), 84.4% vs. 60.2% (p<0.001), 90.8% vs. 71.9% (p<0.001), and 93.5% vs.87.1% (p=0.1), respectively. Anastomosis time was shorter in the barbed group, with a median of 23 vs. 30 minutes (p<0.001). Patients anastomosed with Monocryl suture had smaller prostate weight (median 42.5 g vs. 50 g; p<0.001) and harbored less advanced disease (T2a-c 76.6 vs. 74%; p=0.01) relative to patients treated with V-Loc 180 suture. However, in a multivariate Cox logistic regression analyses, independent predictors of continence recovery were suture type (hazard ratio [HR] 53; 95% confidence interval [CI] 0.41-0.68; p=0.02] and prostate size (HR 0.99; 95% CI 0.98-0.99; p<0.001). CONCLUSIONS: Barbed VUA contributed to delayed continence recovery compared to monofilament poliglecaprone suture during the first year post-RARP. However, no statistically significant difference was recorded at two years post-RARP. These results warrant special attention, especially with the widespread use of barbed suture in recent years.

Testicular ischemia secondary to epididymo-orchitis: A case report.

Testicular infarction is a common urological emergency in clinical practice, it is still underreported when it results from other than spermatic cord torsion. It rarely arises from other pathological processes like vasculitis and infectious disease. We report a case of 18-year-old with epididymo-orchitis complicated by testicular ischemia. This case accentuates the need for a high index of suspicion to rule out concomitant testicular ischemia secondary to epididymo-orchitis that might be salvaged in the future with immediate surgical intervention. Testicular infarction is a devastating complication from epididymo-orchitis that is difficult to predict and distinguish from more common presentations of acute scrotum.

Perioperative predictors for post-prostatectomy urinary incontinence in prostate cancer patients following robotic-assisted radical prostatectomy: Long-term results of a Canadian prospective cohort.

INTRODUCTION: We aimed to report the impact of perioperative factors that have not been well-studied on continence recovery following robotic-assisted radical prostatectomy (RARP). METHODS: We analyzed data of 322 men with localized prostate cancer who underwent RARP between October 2006 and May 2015 in a single Canadian centre. All patients were assessed at one, three, six, 12, and 24 months after surgery. We evaluated risk factors for post-prostatectomy urinary incontinence from a prospectively collected database in multivariate Cox regression analysis. The primary endpoint was continence, defined as 0 pad usage per day. RESULTS: 0-pad continence rates were 126/322 (39%), 187/321 (58%), 222/312 (71%), 238/294 (80%), and 233/257 (91%) at one, three, six, 12, and 24 months, respectively. Bladder neck preservation (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.5-0.99; p=0.04), and prostate size (HR 0.99; 95% CI 0.98-0.99; p=0.02) were independent predictors of continence recovery after RARP. Smoking at time of surgery predicted delayed continence recovery on multivariate analysis (HR 1.42; 95% CI 1.01-1.99; p=0.04). Neurovascular bundles preservation was associated with continence recovery after 24 months. No statistically significant correlation was found with other variables, such as age, body mass index, Charlson comorbidity index, preoperative oncological baseline parameters, presence of median lobe, or thermal energy use. CONCLUSIONS: Our results confirmed known predictors of postprostatectomy incontinence (PPI), namely bladder neck resection and large prostate volume. Noteworthy, cigarette smoking at the time of RARP was found to be a possible independent risk factor for PPI. This study is hypothesis-generating.

Penile Wobble Effect: Proximal Corporal Deformities as a Cause of Penile Prosthesis Failure.

INTRODUCTION: Penile structural defects can contribute toward penile prosthesis (PP) surgical complications and suboptimal outcomes. Despite modern improvements in techniques of inflatable PP (IPP) surgeries, suboptimal outcomes arise secondary to unrecognized proximal corporal abnormalities. AIM: To describe a new observation of IPP failure (wobbly penis) secondary to proximal corporal deformities. METHODS: We performed a retrospective analysis of the Johns Hopkins institutional database of patients who had IPP surgery from May 2006 to March 2017. All cases requiring surgical revisions secondary to proximal corporal deformities were identified. Exclusion criteria included patients who had incidentally discovered proximal corporal deformities intraoperatively or were documented preoperatively to have had a corporal defect. MAIN OUTCOME MEASURES: Successful reimplantation of a functionally intact PP device. RESULTS: On clinical grounds, we identified 5 patients with properly cycling but unstable prosthetic devices that were associated with proximal corporal dilatation (proximally from the penoscrotal junction). All patients underwent reduction corporoplasty with prosthesis replacements consisting of controlled expansion IPPs. 3 patients had undergone previous device replacements because of intact cycling but unstable and unusable IPP devices, whereas 2 had a single previous device insertion. Mean age at revision was 67 years. Median IPP duration was 17 years. Median number of previous IPP surgeries was 3. All patients reported IPP stability and satisfaction after revision (median follow-up = 6 months). CONCLUSIONS: Proximal corporal deformities could account for IPP failure. This condition can be under-recognized as observed in the present cases of multiple revisions with a normally cycling device that was not usable. Proper recognition of this problem allows the opportunity for surgical correction with reduction corporoplasty. Rajih E, Burnett AL. Penile Wobble Effect: Proximal Corporal Deformities as a Cause of Penile Prosthesis Failure. Sex Med 2018;6:267-271.

Functional and oncological outcomes of salvage external beam radiotherapy following robot-assisted radical prostatectomy in a Canadian cohort.

INTRODUCTION: We sought to determine the impact of salvage radio-therapy (SRT) on oncological and functional outcomes of patients with prostate cancer after biochemical recurrence (BCR) following robot-assisted radical prostatectomy (RARP). METHODS: Data of 70 patients with prostate cancer treated with SRT after developing BCR were retrospectively analyzed from a prospectively collected RARP database of 740 men. Oncological (prostate-specific antigen [PSA]) and functional (pads/day, International Prostate Symptom Score [IPSS], and Sexual Health Inventory for Men [SHIM]) outcomes were reported at six, 12, and 24 months after RT and adjusted for pre-SRT status. RESULTS: Men who underwent SRT had a mean age, PSA, and time from radical prostatectomy (RP) to RT of 61.8 years (60.1-63.6), 0.5 ng/ml (0.2-0.8), and 458 days (307-747), respectively. Freedom from biochemical failure (FFBF) post-SRT, defined as a PSA nadir <0.2 ng/mL, was observed in 89%, 93%, and 81%, at six, 12, and 24 months, respectively. Undetectable PSA was observed in 14%, 35%, and 40% at the same time points, respectively. There was no significant difference in urinary continence post-SRT (p=0.56). Rate of strict continence (0 pads/day) was 71% at 24 months compared to 78% pre-SRT. Mean IPSS at six, 12, and 24 months was 3.4, 3.6, and 3.6, respectively compared to pre-RT score of 3.3 (p=0.61). The mean SHIM score pre-SRT was comparable at all time points following treatment (p=0.86). CONCLUSIONS: In this unique Canadian experience, it appears that early SRT is highly effective for the treatment of BCR following RARP with little impact on urinary continence and potency outcomes.

Evaluation of Surgical Outcomes with Photoselective GreenLight XPS Laser Vaporization of the Prostate in High Medical Risk Men with Benign Prostatic Enlargement: A Multicenter Study.

OBJECTIVE: To evaluate the safety and short-term outcomes of photoselective vaporization of the prostate (PVP) using GreenLight XPS™ in treatment of high medical risk (HMR) men. METHODS: A multicenter retrospective analysis of 941 men who underwent PVP between August 2010 and August 2014 was performed. Patients were considered HMR if they had an American Society of Anesthesiologists physical status score ≥3. Postoperative adverse events, unexpected postoperative medical provider visits after intervention, and functional urinary outcomes were examined. RESULTS: HMR men (n = 273) were older (mean age 72.3 ± 8.1 years vs 67.1 ± 9 years, p ≤ 0.01), had larger prostate volumes (82.8 ± 48.2 g vs 73.7 ± 49.4 g, p < 0.01), and were more likely to be on anticoagulant and antiplatelet medications (all p ≤ 0.01). Moreover, overall operative time (65 ± 35.1 minutes vs 53.9 ± 24.9 minutes), energy delivered (313.4 ± 207 kJ vs 258 ± 164 kJ), and energy density used (4.2 ± 3.8 kJ/g vs 3.8 ± 3 kJ/g) were greater in the HMR group (all p ≤ 0.05). Although HMR men were more often treated in a hospital setting (p ≤ 0.01), there were no differences in intraoperative adverse events. At 6 months, both groups had notable improvements from baseline for International Prostate Symptom Score, quality of life due to urinary symptoms, maximum urinary flow rate, postvoid residual urine volume, and prostate-specific antigen. Regarding safety, the two groups had comparable 90-day Clavien-Dindo complication rates, numbers of urgent care visits, and numbers of outpatient consultations. HMR men, however, had more hospital readmissions within 90 days postsurgery (3.7% vs 1.3%; p = 0.04). CONCLUSIONS: Despite older age, greater comorbidity, and significant use of anticoagulants, HMR men who undergo photoselective vaporization benefit from symptom improvement and show no clinical difference in adverse event profiles. GreenLight-XPS produces similar short-term outcomes in patients with significant comorbidities when compared with healthy patients.

Error reporting from the da Vinci surgical system in robotic surgery: A Canadian multispecialty experience at a single academic centre.

INTRODUCTION: The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. METHODS: A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. RESULTS: Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. CONCLUSIONS: Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.